4 HODGES CT - BPA-11-681 REMODEL 2 BEDR. & ADD SKYLIGHTS The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
1, I Massachusetts State Building Code, 780 C'MR, 7ih editionla
OF S.\LEM
Building Permit ApplicationTo Construct. Repair• Renovate Or Demolish 1, v)nx
One-or Two-F mlly Divelling
This Se ion r Official Us nl
Building Permit Number: Date p ted: �� /
' 1""�2� F
Signature: I
Building Commissioner/Inspector of Bw Date
SECTION : 'ITE INFORMATION
),.I Pro erty Address: 1.2 Assessors Map& Parcel Numbers
T !'I0d qe* .t
I.I a Is this an accepted street'?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propoxd Use Lot Arca(sy Il) Frontage(It)
I.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. -Owner'of R4cord: C�2T
plod eS
Name.(Pri ) (J�/yUQ(//�p Address foCuS6rvice:
Signature v telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ a er of Units_ Other ❑ Specify:
Brief Descriptionol'Proposed Work'•
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials ORlcial Use Only
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing .S 2. Other Fees: S -
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire
Su ression S Total All Fees:S
6.Total Project Cost: S Check No._Check Amount: Cash Amount:
06� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�— li.t iration Date
License Number P
Name of CSI.- Ilolder List CSL I)pe(see below)
fs 1),wn don
Address U Unrestricted(up to J5,000 Cu.Ft.
R Restricted 1&2 Family Owellin
Signature M btusun Only -
RC' Residential Routing overmig
I e1cphone WS Residential Window and Man
SF Residential Solid Fact Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Registration Number
I IIC•Company Name or I IIC Registrant Name
Address Expiration Date
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No..........•0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
- to act on my behalf,in all matters
authorize
relative to work authorized by this building permit application.
Signature of owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I,
L tJU cI 6 5 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
,behalf.
Print Name R o Li
(�ILUa.
Signature of Owner or Authorized Agent Vale
(Signed under the pains and penalties of r'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will!Lof have access to the arbitration
pmgram or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted fix"Total Project Cost"